Provider Demographics
NPI:1750567442
Name:IRELAND GROVE CENTER FOR SURGERY LLC.
Entity type:Organization
Organization Name:IRELAND GROVE CENTER FOR SURGERY LLC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:
Authorized Official - Last Name:KOLB
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:309-664-0101
Mailing Address - Street 1:3801 IRELAND GROVE ROAD
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61704
Mailing Address - Country:US
Mailing Address - Phone:309-664-0101
Mailing Address - Fax:309-664-1010
Practice Address - Street 1:3801 IRELAND GROVE ROAD
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61704
Practice Address - Country:US
Practice Address - Phone:309-664-0101
Practice Address - Fax:309-664-1010
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-14
Last Update Date:2025-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1538168786OtherNPI
IL1760543615OtherNPI
IL1992813174OtherNPI
IL1558347310OtherNPI
IL1164419818OtherNPI
IL1285633420OtherNPI
ILIL1464OtherPTAN